Birmingham and Solihull Mental Health NHS Foundation Trust

We rated community based mental health services for adults of working age as good because:

• All locations where patients were seen and treated had access to emergency equipment.

• All buildings were clean and well maintained.

• There was adequate hand washing facilities and we observed staff following infection control practices.

• Patients and carers were happy with the way that staff worked and the services that were offered to them.

• Patients felt that their needs were met and that the services belonged to their community.

• Staff felt supported by senior managers and told us that they were able to share their concerns with the chief executive officer for the trust.

We rated Forensic inpatient/secure as Good because:

• Staff could observe all areas of the wards at Ardenleigh, Reaside and The Tamarind Centre and at Hillis Lodge. They used risk assessments and observations to mitigate the potential risks to patients. Wards had adequate levels of staffing to meet the needs of patients and used bank and agency staff who were familiar with wards and patients where possible.

• Wards had a full range of mental health disciplines and staff had the skills necessary to carry out their roles. Training levels in the Mental Capacity Act and Mental Health Act were high and staff felt confident to use this legislation to support patients.

• Staff demonstrated that they understood the individual needs of patients who said they were respectful and friendly. Staff provided activities that met the needs of patients and supported them to develop skills for independent living.

• Staff felt motivated and well supported to do their jobs. Managers listened to their concerns and responded to these. Staff had opportunities for professional development.

• At Ardenleigh, patients needing seclusion had to be taken through a children and adolescents ward to use a seclusion room. This could affect the safety, dignity and privacy of the patients.

• At Ardenleigh, the womens service had accessed seclusion facilities via the adolescent ward.

• Staff used different tools for risk assessment and care planning which meant that at times the quality of these was inconsistent which could affect the care of patients.

• There was no standard approach to recording capacity in the records and whether patients had been read their rights under the Mental Health Act.

• Audits and governance structures were not sufficient to ensure quality of documentation and medication and clinical equipment errors were identified.

• Fridge and clinic room temperatures had not always been recorded and some equipment such as needles were out of date on some wards. Some wards had excessive stock of medication did not record the date this was opened.

We rated mental health crisis services and health-based places of safety as requires improvement because:

• Night time staffing of the crisis resolution home treatment team and RAID teams often fell below planned staffing levels.
• Medicines management practice was not robust across all teams. We found that there were gaps in medicines reconciliation, transportation in community teams and documenting of patients’ allergy status.
• We found that staff at the health based place of safety did not consistently monitor the quality and completeness of monitoring forms completed by staff.
• We found that patients and staff did not always have access to alarm points, and alarm systems at trust locations had not been effectively checked to ensure they worked.

However:

• Patients reported that staff were caring, polite and respectful and we saw this demonstrated in our observations.
• Staff reported that teams worked well, were supportive and worked hard to deliver patient care.

Following the inspection in March 2017, we have changed the overall rating for Birmingham and Solihull Mental Health NHS Trust from Good to Requires Improvement because:

• Feedback from staff and evidence from the most recent NHS staff survey suggested a disjoint between the board and staff at service level. Staff groups in several areas reported feeling under-valued and as being unheard concerning key decisions and service re-design.
• The trust had taken a blanket approach to searches and ordering of food from take away restaurants. The decisions made at board level in relation to the restrictions did not take account of individual risk assessment or patient choice.
• The oversight and safety of medicines management was compromised as the trust did not have a medicines safety officer in post. The trust policy concerning rapid tranquilisation was also out of date and did not reflect updated guidance from the national institute of health and care excellence.
• Staff knowledge, understanding and application of the Mental Capacity Act was poor in those community services that cared for children and young people and in the wards for older people with mental health problems.
• We found that the trust processes for assuring their contractual obligations concerning equality and diversity lacked robustness. In some teams, the provision of information for Non-English speakers was insufficient and in contravention with the Equality Act 2010.
• The Board Assurance Framework did not focus on strategic risks and instead was an extension of the corporate risk register. This meant that the board were unable to provide robust evidence of an understanding of the trusts corporate risks.

However:

• Staff, throughout the organisation, were caring, compassionate, kind and treated patients with dignity and respect. Feedback from patients and carers was positive and highlighted the staff as a caring group.
• Staffing levels across the trust were generally safe and sufficient to provide good care.
• The trust was involved in several vanguards and new models of care partnerships with external partners. Overall, external bodies were positive about the trust and its role in addressing the challenges faced by the local health economy.
• Trust services were responsive to the needs of the patient group; this was evident in the inpatient and community services that we visited.

We rated wards for older people with mental health problems as good because:

• Staff took time to explain, orientate and re-assure patients as appropriate, supporting them to be safe but also to be as independent as possible. Ward managers were able to adjust staffing levels to take account of the fluctuating needs of patients, so that patients had additional support when they needed it. The service had a low rate of serious incidents. Staff used de-escalation techniques wherever possible as an alternative to restraint or seclusion. Positive comments by patients and visiting relatives reflected the good work by staff.

• The teams worked together effectively to resolve care and treatment issues. Wards had access to support from a variety of clinicians and other professionals. Psychology support was available to help support staff in understanding and resolving patient behaviours. Medical support was available promptly. Occupational therapists provided activities and assessments to help patients gain or regain skills and enhance their well-being.

• Care records were up to date, needs assessments and physical health care checks took place promptly after assessment. Monitoring systems were in place to ensure patient well-being.

• Wards were clean and there was a range of rooms and equipment to support treatment and care.

• Food was good and highly rated by patients. Patients were able to get snacks and drinks at any time of day or night.

• Staff morale was good; staff expressed confidence in being able to report anything of concern. Staff were very positive about their teams and the support from immediate managers and sickness and absence rates were below the national average. Effective systems ensured staff received training, supervision and appraisals.

However:

• The service was administering medication for physical health conditions covertly without appropriate safeguards in place for detained patients. There appeared to be no distinction between the procedure for administering medicines covertly for mental health needs and those for physical health needs.

• Some mental capacity assessments were only partially completed on Rosemary and Bergamot wards.

• Cleaning checklists were not always completed on Rosemary ward, indicating that equipment may not have been checked and cleaned as often as it should be.

• There was a lack of suitable short-term rooms for patients when they presented a risk to themselves or other patients. Many staff felt patients might benefit from having a purpose-made de-escalation room available.

• Lounge areas on the three Juniper wards were relatively small and were frequently crowded.

We rated the community based mental health services for older people as good because:

• Staff routinely completed and updated patient risk assessments. They developed and recorded crisis plans with patients. This meant there were plans in place to reduce risks if patients were in crisis. Staff had a good understanding of safeguarding and the procedures to keep people safe from abuse. The service carried out regular environmental risk assessments to monitor and improve the safety of buildings.

• The service had clear policies to support staff when they worked alone. Staff were aware of the lone working policy and the procedures to follow if they needed support when working alone. Staff knew how to report incidents and felt able to report concerns.

• Staff knew their patients well. They kept records of patient care and treatment up-to-date, including any changes in circumstances. Staff routinely carried out mental capacity assessments when necessary and supported patients to manage their physical health needs.

• The service worked well with other teams and agencies to enable patients to move between services as their needs changed. Staff communicated promptly and effectively with patients’ GPs and other relevant agencies.

• Staff treated patients with kindness, dignity and respect. They routinely involved patients and carers in developing their assessments and care plans. The service was responsive to the needs of patients, carers and care homes. Patients told us they could get appointments when they needed them and doctors were accessible to both staff and patients. They said they could contact their allocated worker if they needed to speak with them. Patients were very positive about the service they received. The trust employed a team to gather feedback from patients and carers and used the information to make improvements to the service.

• Staff had access to regular supervision and there were some opportunities for them to develop their skills and career. They were up-to-date with their mandatory training. Staff had a working knowledge of the Mental Health Act and the Mental Capacity Act.

• Local leaders were visible and accessible to staff. Senior managers sometimes visited the teams.

• Managers carried out regular audits, including audits of patient records. The service recorded referral and discharge data. They used dashboards to inform staff and managers if they were meeting their key performance indicator targets. This meant they could tell how long people waited to be seen by the teams and if staff carried out reviews in a timely manner.

However:

• The service did not have a consistent process to audit safe and secure handling of medicines within the community teams. The trust pharmacy team carried out audits at each site in early 2017 but prior to this, there were gaps of over three years in some teams. There was no effective monitoring of clinic room temperatures in three teams and the clinic rooms in two teams were dusty and cluttered. Staff in most teams told us they believed their caseloads were too high and many told us they felt they needed to work at home, in their own time, to perform essential activities such as updating care plans and risk assessments.

• Caseloads were high and some staff worked unpaid hours to complete essential case recording.

• In some areas of the service, staff told us there were long waiting times for patients to access psychological therapies. The trust told us the longest waiting time was four weeks.

• Most carers and patients did not know how to make a complaint about the service. Despite this, they told us they were sure they could find out how make a complaint if they needed to and were confident they would be listened to.

• Consulting rooms where staff saw patients at the East Hub were very poorly soundproofed which meant conversations could be easily overheard. Consulting rooms at the North Hub had glass panels, which meant people using the corridor, could easily look in.

• Some staff felt senior managers did not listen to the feedback they provided about organisational change and they had not received a response when they had used the trust formal feedback process called “Dear John”. Three staff said they did not have confidence in the whistleblowing process or in the Dear John process.

• A number of staff felt unsettled about the organisational changes taking place within the trust and this led to a degree of low morale within most teams.

We rated specialist community mental health services for children and young people as inadequate because:

• Consent to treatment had not been established or recorded in 89% of care records reviewed during our inspection. We found no evidence of the consideration of Gillick competence in all care records reviewed and we did not find evidence of the documentation of parental responsibility in 98% of care records reviewed.
• Care planning documentation was not routinely used and care plans were not completed in line with the trust's procedures or shared with young people and their families. A recent audit at the eating disorder service found there were no completed care plans in all 23 records reviewed.
• Risk assessments for people using the service were not routinely completed or in a consistent format. We found that risk assessments completed on the trust's risk screening tool were absent in 28% of the records reviewed. Crisis and contingency plans lacked detail and personalisation for young people and their support networks.
• There were ligature risks at both community sites visited. Children and young people had access to rooms with ligature points which could be internally locked preventing entry by staff. Interview rooms were not fitted with alarms and personal safety protocols including lone working policies were not consistently followed.
• Policies and procedures relating to the running of the service had not been reviewed in line with identified timescales. The policy for the use of the Mental Health Act made reference to the 1983 Code of Practice rather than the updated 2015 version.
• Prescription pads were not stored securely in line with trust policy and there was no pharmacy oversight or audit of the prescribing practice in the community service.
• Physical health monitoring equipment at the both community locations had not been checked or calibrated in line with manufacturers recommendations. Cleaning schedules and maintenance audits were not in place for toys made available for the use of children and young people.
• Staffing vacancies and turnover fro the previous year were high at 30% and 25% respectively. The Solar service was on the trust's risk register for staffing at the time of our inspection.
• Staff attendance at mandatory training was below the trust and national targets. Managerial supervision and appraisal had not been happening consistently and was not recorded following trust guidance and policies.
• The eating disorder service had a shared reception with other primary care services. At the time of our inspection, there were not effective systems for monitoring people entering or leaving the building and we found the reception area unstaffed on multiple occasions. The unsuitability of the premises was on the trust risk register at the time of our inspection.
• There had been high use of bank and agency staff, and the turnover rate of staff in the 12 months prior to our inspection was 25%. Staffing for the service was on the trust's risk register at the time of our inspection.
• Facilities did not always meet the needs of the people using them. There was a lack of child and young person appropriate activities at the Freshfields clinic and the décor was bare and not child friendly. Interview rooms at both community locations did not have effective soundproofing and information was not available in a range of languages or child friendly formats.

However:

• Referral to treatment times were within national targets. The eating disorder service was meeting the new national access and waiting time standard effective from April 2017.
• The service worked effectively with partner agencies including the local multi-agency safeguarding hub, the police and local schools. Staff provided a flexible approach to working with children, young people and their families, and service provision was being extended by a newly developed crisis team.
• Feedback from children, young people and their families using the service was positive. The service provided access to a range of psychological therapies and interventions including specialist training for foster carers and families.
• Morale amongst staff was high. Staff reported a culture of mutual support and joint working. Staff provided feedback that the new team manager and service lead were effective, visible and making changes to increase the services effectiveness.
• Children, young people and their families were able to provide feedback about their experiences of receiving care and support. Advocacy services were available and young people were involved in the recruitment of staff, including the new team manager.

We rated Birmingham and Solihull Mental Health NHS Foundation trust’s child and adolescent mental health wards as good because:

• Young people received care and support according to their individual needs. Staff formed strong relationships with young people and their families, who all told us staff treated them with respect, kindness and compassion. Young people, families and staff worked in true partnership when planning care and setting individual goals.

• Staff were encouraged to be innovative and improve the service. Recent quality improvement work to reduce incidents of violence and aggression had started to lead to a reduction in use of restraint and rapid tranquilisation.

• Young people were involved within the service at different levels. From running activities to reflecting with staff on how the day had gone. They could contribute to improving the environment, be part of governance groups and help with the recruitment of staff.

• Care records were of a high quality and included the voice of the patient and families/ carers where appropriate. Risk assessments and management plans were thorough and updated as needed.

• Effective governance processes were in place. Staff reported incidents and learnt lessons. Staff took time to reflect on clinical practice and looked at how they could improve outcomes for patients.

However:

• The trust policy for rapid tranquilisation did not incorporate the latest National Institute of Clinical Excellence (NICE) guidelines published in May 2015 and we found young patients had been prescribed medicine outside of the current guidelines.
• The seclusion room on Larimar Ward had no clock.
• Patients on Atlantic and Pacific did not always have access to the seclusion room. In the last six months, staff had used the room to seclude an adult patient, three times.

• Patients on Larimar Ward had no access to a multi-faith room and access to outside space was limited.

• Larimar Ward is next to adult wards. Commissioning arrangements placed restrictions on the rights of an informal patient to leave the ward. Informal patients were unable to leave the ward without a staff escort.

• We found some section 17 Mental Health Act forms to be incorrectly completed.

We rated acute wards for adults of working age and psychiatric intensive care units as requires  improvement because:

• We found that the trust had not met all the requirement notices from our inspection in 2014. Ligatures were still an issue and fridge temperatures not being recorded consistently which meant that patient safety could be put at risk. At Newbridge House, Eden PICU, Eden Acute ward and George ward; we saw blind spots on ward areas that were not mitigated by staff observation or blind spot mirrors.

• Documentation was poor in some areas. We found some issues with Mental Health Act documentation and recording such as Section 17 paperwork not always showing detail of the conditions of leave or the number of escorts’ required and capacity to consent to treatment forms in 43% of the patient records we looked at were not decision specific and did not show how decisions about a patients capacity had been made.

• The trust had a blanket search policy for patients returning from section 17 leave. This was not risk assessed or care planned to meet the needs of individual patients. Wards did not always apply this consistently and in line with the trust policy.

• Healthcare assistants did not have access to training in the Mental Health Act and Mental Capacity Act. This training would help them to support patients in understanding the restrictions placed on them.

However:

• Staff training levels were high and we found a well-motivated and engaged staff group. Consideration had been given to staff development and we found that a high number of staff had received specific training to give them the skills to take on extra responsibilities within their role.

• We observed staff to be caring and patient focussed. Care plans were complete and contained all the information that staff required to deliver care. We also saw that the trust is committed to patient involvement in service development. The trust had introduced peer support workers who were individuals that had accessed services in the past.

• Staff reported that they felt supported by their local managers. They stated that they felt that their managers went over and above to ensure that staff felt valued. We also found that teams supported each other and worked well together.

We rated the Long stay rehabilitation mental health wards as good because:

• We found the units to be clean, spacious and comfortable with good quality furnishings and décor throughout, including well-maintained gardens.
• Staff interactions with patients were appropriate and demonstrated a good understanding of individual patient needs.
• Patients had the choice of a wide range of therapeutic interventions and activities to aid rehabilitation.
• Carers were involved in the care of their relatives. We saw resources for carers and information on carers groups. Each unit had a carers champion /lead.

However;

• Medicines management practices were inconsistent and potentially put patients at risk. We found discrepancies relating to the storage, prescribing and administration of medicines.